Citation Nr: 1315006 Decision Date: 05/07/13 Archive Date: 05/15/13 DOCKET NO. 09-35 079 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for throat cancer, including as secondary to Agent Orange exposure. 3. Entitlement to service connection for a bilateral hip disorder. 4. Entitlement to service connection for a left knee disorder. 5. Entitlement to service connection for lymph node cancer, including as secondary to Agent Orange exposure. 6. Entitlement to service connection for left shoulder melanoma. 7. Entitlement to service connection for coronary artery disease, including as secondary to Agent Orange exposure. REPRESENTATION Appellant represented by: Oregon Department of Veterans' Affairs ATTORNEY FOR THE BOARD Hallie E. Brokowsky, Counsel INTRODUCTION The Veteran had active service from December 1962 to December 1965. The Veteran died on March [redacted], 2010. The appellant is the Veteran's surviving spouse, who is substituted as the appellant for purposes of adjudicating the Veteran's claims to completion. 38 U.S.C. § 5121A (allows for substitution in case of death of a claimant who dies on or after October 10, 2008). This matter came before the Board of Veterans' Appeals (Board) on appeal from a November 2006 rating action of the Portland, Oregon, Regional Office (RO). The Veteran's claims file was subsequently transferred to the RO in Waco, Texas. The Board has not only reviewed the Veteran's physical claims file, but also the Veteran's file on Virtual VA, to ensure a total review of the available evidence. In Clemons v. Shinseki, 23 Vet. App. 1 (2009), the United States Court of Veterans Appeals (Court) held that a claim for service connection for PTSD also encompasses claims for service connection for all psychiatric disabilities afflicting a veteran based on a review of the medical evidence. The Veteran originally filed a claim of entitlement to service connection for PTSD, but the evidence of record shows that he has also been diagnosed with depression. As such, the Board recharacterized the issue on appeal as indicated. The Board notes that, pursuant to his request in his substantive appeal, the Veteran requested a hearing before the Board. However, the Veteran died before such a hearing could be held, and the appellant withdrew the hearing request in September 2012. As such, the Board will proceed with its review on the present record. See 38 C.F.R. § 20.704(d), (e). The issues of entitlement to service connection for an acquired psychiatric disorder, to include PTSD, and melanoma of the left shoulder are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran did not engage in combat with the enemy during service. 2. The Veteran served in the Republic of Vietnam from May 1965 to December 1965, where he was exposed to herbicides. 3. The Veteran had cancer of the throat, including the larynx. 4. The Veteran did not sustain a disease or injury of the hips during service. 5. The Veteran did not experience chronic symptoms of a bilateral hip disorder during service. 6. The Veteran did not experience continuous symptoms of a bilateral hip disorder after service. 7. Arthritis of the bilateral hips did not manifest within one year of separation from service. 8. The Veteran did not sustain a disease or injury of the left knee during service. 9. The Veteran did not experience chronic symptoms of a left knee disorder during service. 10. The Veteran did not experience continuous symptoms of a left knee disorder after service. 11. Arthritis of the left knee did not manifest within one year of separation from service. 12. The Veteran had chronic lymphocytic leukemia. 13. The Veteran had coronary artery disease. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for throat cancer are met. 38 U.S.C.A. §§ 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2012). 2. The criteria for service connection for a bilateral hip disorder are not met. 38 U.S.C.A. §§ 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2012). 3. The criteria for service connection for a left knee disorder are not met. 38 U.S.C.A. §§ 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2012). 4. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for chronic lymphocytic leukemia are met. 38 U.S.C.A. §§ 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2012). 5. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for coronary artery disease are met. 38 U.S.C.A. §§ 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In this case, the agency of original jurisdiction (AOJ) issued a notice letter, dated in August 2006, to the Veteran. This letter explained the evidence necessary to substantiate the Veteran's claims for service connection, as well as the legal criteria for entitlement to such benefits. The letter also informed him of his and VA's respective duties for obtaining evidence. The AOJ decision that is the basis of this appeal was decided after the issuance of an initial, appropriate VCAA notice. As such, there was no defect with respect to timing of the VCAA notice. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). VA also has a duty to assist a veteran with the development of facts pertinent to the appeal. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). This duty includes the obtaining of "relevant" records in the custody of a Federal department or agency under 38 C.F.R. § 3.159(c)(2), as well as records not in Federal custody (e.g., private medical records) under 38 C.F.R. § 3.159(c)(1). VA will also provide a medical examination if such examination is determined to be "necessary" to decide the claim. 38 C.F.R. § 3.159(c)(4). In this case, the claims file contains the Veteran's service treatment records and a report of private and VA post-service treatment and evaluation, as well as the Veteran's own statements in support of his claims. The Veteran was examined by VA in connection with his respiratory cancer claims in 2009. The Board has reviewed the examination reports, and finds that they are adequate for the purpose of deciding those issues; the examination reports contain all the findings needed to evaluate the disability, including history and clinical evaluation. The Veteran was not examined by VA in connection with his claims for service connection of a bilateral hip disorder and a left knee disorder, but, as will be explained below, the evidence does not demonstrate a related injury, disease, or event during service; therefore, no examination or nexus opinion is required, and any opinion would be speculative, as there is no injury, disease, or event during service to which such currently diagnosed bilateral hip or left knee disorder could be related. For this reason, a remand to provide the Veteran with a medical examination and/or obtain a medical opinion is not required with respect to the claims for service connection for bilateral hip disorder and a left knee disorder. See Bardwell v. Shinseki, 24 Vet. App. 36 (2010) (where the Board makes a finding that lay evidence regarding an in-service event or injury is not credible, a VA examination is not required). Additionally, the Veteran was not examined with regard to his claims for service connection for cancer of the lymph nodes and coronary artery disease; however, as service connection for these claims will be granted as part of this decision, no examination is required. The Board has reviewed the Veteran's statements and medical evidence of record and concludes that there is no outstanding evidence with respect to the Veteran's claims. For these reasons, the Board finds that the VCAA duties to notify and assist have been met. Legal Criteria for Service Connection It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a) (West 2002). In this case, the Board has thoroughly reviewed all of the evidence in the Veteran's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his or her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Court held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. See Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Court has also stated, "It is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert, 1 Vet. App. at 57. Service connection may be granted for disability or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection for a disability on the basis of the merits of such claim requires (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). In addition, the law provides that, where a veteran served ninety days or more of active service, and certain chronic diseases, such as arthritis, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a) (2012). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. The Veteran has been diagnosed with a "chronic disease" of arthritis listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) applies to the claims of service connection for hip and knee disorders. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Veteran has been diagnosed with degenerative joint disease of the hips and left knee, which is arthritis. Nonetheless, the Veteran's claimed throat and lymph cancers, and coronary artery disease are not listed as a "chronic disease" under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) does not apply to those disabilities. Arthritis is listed as a "chronic disease" under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) applies to that disability. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See 38 U.S.C.A. § 1153(a) (West 2002); 38 C.F.R. § 3.303(a); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) and Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). In certain circumstances, however, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. See 38 C.F.R. § 3.310(a) (2012); Harder v. Brown, 5 Vet. App. 183, 187 (1993). Additional disability resulting from the aggravation of a nonservice-connected condition by a service-connected condition is also compensable under 38 C.F.R. §3.310(a). See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to establish presumptive service connection for a disease associated with exposure to certain herbicide agents, the Veteran must show the following: (1) that he served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975; (2) that he currently suffers from a disease associated with exposure to certain herbicide agents enumerated under 38 C.F.R. § 3.309(e); and (3) that the current disease process manifested to a degree of 10 percent or more within the specified time period prescribed in section 3.307(a)(6)(ii). 38 U.S.C.A. § 1116; 38 C.F.R. §§ 3.307(a)(6), 3.309(e). The law provides that, if a veteran was exposed to a herbicide agent during active service, presumptive service connection is warranted for certain disorders delineated under 38 C.F.R. § 3.309(e). Respiratory cancers, chronic lymphocytic leukemia, and ischemic heart disease (including coronary artery disease) are among the diseases listed in 38 C.F.R. § 3.309 for which presumptive service connection is available based on in-service herbicide exposure. The Secretary, under the authority of the Agent Orange Act of 1991, Public Law No. 102-4, 105 Stat. 11, and based on the studies by the National Academy of Sciences (NAS), has determined that there is no positive association between exposure to herbicides and any condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 59 Fed. Reg. 341-46 (1994); see also Notice, 61 Fed. Reg. 41,442-49, and 61 Fed. Reg. 57,586-89 (1996); Notice, 64 Fed. Reg. 59,232-43 (Nov. 2, 1999); Notice, 67 Fed. Reg. 42,600-08 (June 24, 2002); Notice, 72 Fed. Reg. 32,395-407 (June 12, 2007); Final Rule, 74 Fed. Reg. 21,258-60 (May 7, 2009); Final Rule, 75 Fed. Reg. 53,202-16 (Aug. 31, 2010). The availability of presumptive service connection for a disability based on exposure to herbicides does not preclude a veteran from establishing service connection with proof of direct causation, or on any other recognized basis. Stefl v. Nicholson, 21 Vet. App. 120 (2007); see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Analysis of Service Connection Throat Cancer, Lymph Node Cancer, and Coronary Artery Disease The Veteran contended that his throat cancer, lymph node cancer, and coronary artery disease were due to his service in Vietnam. In this Veteran's case, the evidence does not show, nor does the Veteran allege, that he engaged in combat with the enemy during active service. The Board also finds that there is no objective evidence that the Veteran "engaged in combat with the enemy." For this reason, 38 U.S.C.A. § 1154(b) is not applicable in this case. Nevertheless, the Board finds that the evidence is in favor of the Veteran's claim for service connection for throat cancer, chronic lymphocytic leukemia, and coronary artery disease, as secondary to herbicide exposure during service in the Republic of Vietnam. The Veteran's service treatment records and service personnel records (DD Form 214) show that he had active service in the Republic of Vietnam from May 1965 to December 1965. Given the foregoing, the Board finds that the circumstances of the Veteran's active service included in-country duty in Vietnam. Because the Veteran had in-country duty in Vietnam, his active service meets the regulatory definition of Vietnam service found in 38 C.F.R. § 3.307(a)(6)(iii). See Haas v. Peake, 525 F.3d. 1168 (Fed. Cir. 2008) cert. denied 129 S. Ct. 1002 (2009) (upholding as permissible VA's regulatory interpretation of "service in Vietnam" as requiring in-country duty or visitation in Vietnam). Because the Veteran had active service in Vietnam, his in-service exposure to herbicides (Agent Orange) is presumed. See 38 C.F.R. §§ 3.307, 3.309. VA treatment records show that the Veteran has been diagnosed with coronary artery disease and private treatment records show that he had cardiomyopathy. Additionally, these records showed treatment for cancer of the oropharynx and lymph nodes. According to the April 2009 VA examination report, the Veteran had squamous cell carcinoma of the tongue base, hypopharynx, and upper larynx area. Although the Veteran's treatment records did not provide specificity as to the nature of his cancer of his lymph nodes, the Board observes that the Veteran's death certificate indicates that he had chronic lymphocytic leukemia. The Board further observes that the provisions of 38 C.F.R. § 3.309(e) specifically permit a grant of service connection for ischemic heart disease (including coronary artery disease), chronic lymphocytic leukemia, and cancer of the respiratory system (including the larynx) on a presumptive basis, as long as there is competent medical evidence establishing that the Veteran had a current diagnosis and proof of service in the Republic of Vietnam. As the Veteran is presumed to have been exposed to herbicides during active service in Vietnam, and has been diagnosed with ischemic heart disease, chronic lymphocytic leukemia, and oropharyngeal cancer to include the larynx, service connection for throat cancer, cancer of the lymph nodes, and coronary artery disease is warranted on a presumptive service connection basis. 38 C.F.R. § 3.309(e). Bilateral Hip Disorder and Left Knee Disorder The Veteran contended that his claimed bilateral hip and left knee disorders are due to playing football in service. As previously discussed, 38 U.S.C.A. § 1154(b) is not applicable in this case. After a review of the evidence, the Board also finds that the evidence shows no in-service injury or disease, including no diagnosis of a bilateral hip or left knee injury or disorder in service, and that symptoms of a bilateral hip or left knee disorder were not present in service. In this case, the service treatment records do not show any complaints, treatment, or diagnoses related to a bilateral hip or left knee disorders. See 38 C.F.R. § 3.303(a). Additionally, a December 1965 service separation examination was negative for any orthopedic disorders, to include of the hips or left knee, and he denied any joint symptomatology on a concurrent report of medical history. The Board also finds that the weight of the evidence demonstrates that the Veteran, during his service, did not experience symptoms of a bilateral hip or left knee disorder, or for many years thereafter. Although the Veteran is competent to report certain symptoms related his hips and left knee, the Board observes that the Veteran first complained about his hips in April 2005, nearly 40 years after leaving service; at that time, he reported duration of pain for 4 to 5 months, without a history of specific injury or trauma. As for his left knee, he was first treated for a left knee disorder by VA in May 2003. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (service incurrence may be rebutted by the absence of medical treatment for the claimed condition for many years after service). As the statements regarding onset of post-service hip and left knee disorders beginning years after service separation were made to VA physicians in May 2003 and April 2005, during the course of treatment, they are afforded greater probative weight than those statements made in conjunction with the August 2006 claim for VA disability compensation benefits submitted by the Veteran contending that his symptoms either began in service or were aggravated during service. Such statements made to physicians for the purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care. In weighing credibility, which the Board finds to be the key issue in this case, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See generally Caluza, supra. After a review of all the evidence, lay and medical, the Board finds that the weight of the evidence demonstrates that the Veteran did not sustain a disease or injury of the bilateral hips or left knee during service, and did not have symptoms of a bilateral hip or left knee disorder during or immediately following service. In this case, the service treatment records do not show any complaints, treatment, or diagnoses related to a bilateral hip or left knee disorder within one year of discharge. See 38 C.F.R. § 3.303(a). Significantly, the Veteran did not make any assertions that his bilateral hip or left knee disorders are related to his service until he filed his claim for benefits in 2006. See Pond v. West, 12 Vet. App. 341 (1999) (although Board must take into consideration the appellant's statements, it may consider whether self-interest may be a factor in making such statements); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). The Board has also considered the statements of the Veteran, attesting that the he had a history of hip and left knee symptoms since his service; however, the Board finds that the recent assertions of the Veteran are not credible because his recent assertions are inconsistent with the absence of complaints or treatment after service and the Veteran's own histories made for treatment purposes prior to filing his 2006 claim for VA compensation, and is inconsistent with the Veteran's own reported histories when seeking treatment in the intervening years. See Cromer v. Nicholson, 19 Vet. App. 215, 217 (2005). Prior to the 2006 claim for benefits, it is significant that the Veteran did not make any assertions of chronic hip or left knee symptoms in service or continuous symptoms since service, and he did not assert a link between his service and his symptoms or assert an in-service onset at that time. Such evidence weighs against findings of symptoms of a bilateral hip or left knee disorder in service or symptoms since service. The Board finds that the weight of the lay and medical evidence of record reflects that the Veteran's bilateral hip and left knee disorders had post-service onset and are not related to the Veteran's active service; the Veteran was diagnosed with degenerative joint disease many years after service. Medical evidence is not limited to that which is provided by doctors. Cox v. Nicholson, 20 Vet. App. 563 (2007). Additionally, the Veteran did not attempt to provide explanations for why there were no noted symptoms in service or for many years after service. For these reasons, the Board finds that the lay and medical evidence that is of record weighs against the claims for service connection for bilateral hip and left knee disorders. Because the preponderance of the evidence is against the claims, the benefit of the doubt doctrine is not for application, and the claims must be denied. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for throat cancer is granted. Service connection for a bilateral hip disorder is denied. Service connection for a left knee disorder is denied. Service connection for chronic lymphocytic cancer is granted. Service connection for coronary artery disease is granted. REMAND As discussed in the decision above, review of the Veteran's official military documentation contained in his claims file does not indicate that he engaged in combat against enemy forces as contemplated by VA regulations. While his service personnel records confirm that the Veteran served in Vietnam from May 1965 to December 1965, these records do not reflect that he received any decorations or medals indicative of involvement in combat. Therefore, the Board finds that he did not "engage in combat" and the evidentiary presumption of 38 U.S.C.A. § 1154(b) and 38 C.F.R. § 3.304(f) does not apply. See VAOPGCPREC 12-99. As a result, any alleged stressors in service must be independently verified, i.e., corroborated by objective credible supporting evidence The Veteran submitted statements to the RO in January 2007 and October 2009, in response to a PTSD Questionnaire, so that the RO could attempt to verify any alleged stressors. The Veteran's service personnel records were associated with his claims file. However, the RO made no attempt to obtain any unit histories or other records for the Veteran's unit from the United States Army and Joint Services Records Research Center (JSRRC), the National Personnel Records Center (NPRC), or the National Archives and Records Administration (NARA). Information regarding the Veteran's assignments and his unit's history is required to verify his purported stressors. VA must make reasonable efforts to assist the Veteran in obtaining evidence necessary to substantiate the claim for the benefit sought unless no reasonable possibility exists that such assistance would aid in substantiating the claim. See 38 U.S.C.A. § 5103A(b), (c) (VA must make a "reasonable effort" to obtain all relevant records, including records pertaining the claimant's service). The Board further observes that diagnoses of PTSD and depression are of record, but that it is unclear whether any of the Veteran's alleged stressors is sufficient to form the basis of a diagnosis of PTSD. As a result, although PTSD has been diagnosed, the stressor event that was objectively confirmed was not cited as one of the grounds for diagnosing PTSD. So a VA psychiatric opinion must be obtained, indicating whether any of the events listed in the aforementioned unit histories supports the PTSD diagnosis. See 38 C.F.R. §§ 3.304(f), 4.130 (service connection for PTSD requires medical evidence establishing a diagnosis of the condition in accordance with 38 C.F.R. § 4.125(a), credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor). Additionally, it is unclear if his depressive disorder is causally or etiologically related to his service. Likewise, the Board notes that the Veteran asserted that his left shoulder melanoma, excised in 1991, is related to his military service, including his service in Vietnam. The treatment records for the excision have not been associated with the claims file, but post-service treatment records consistently show that he was treated for melanoma of the left shoulder in 1991. Nevertheless, the medical evidence is unclear whether the Veteran's melanoma of the left shoulder was causally or etiologically related to the Veteran's military service, including his exposure to Agent Orange while in Vietnam. See McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006). See also 38 U.S.C.A. § 5103A(d)(1); 38 C.F.R. § 3.159(c)(4) (VA has an affirmative duty to obtain an examination of the claimant at Department health-care facilities if the evidence of record does not contain adequate evidence to decide a claim). VA adjudicators may consider only independent medical evidence to support their findings; they may not rely on their own unsubstantiated medical conclusions. If the medical evidence of record is insufficient, VA is always free to supplement the record by seeking an advisory opinion, or ordering a medical examination to support its ultimate conclusions. See Colvin v. Derwinski, 1 Vet. App. 171 (1991). Accordingly, the Board finds that the Appellant should be afforded a VA medical opinion. See 38 U.S.C.A. § 5103A(d)(1); 38 C.F.R. § 3.159(c)(4) (VA has an affirmative duty to obtain an examination of the claimant at VA health-care facilities if the evidence of record does not contain adequate evidence to decide a claim). Accordingly, the case is REMANDED for the following action: 1. Request any/all additional available service personnel records from NARA, the NPRC, and the Defense Personnel Records Imaging System. These agencies also should be requested to furnish the unit history for the unit to which the Veteran was assigned in Vietnam. If no additional service records or unit histories can be found, or if they have been destroyed, ask for specific written confirmation of that fact. 2. With the information provided by the Veteran in January 2007 and October 2009, review the file and prepare a summary of all the claimed stressors. Send this summary and a copy of his DD Form 214 and all associated service documents to the JSRRC. The JSRRC should be requested to provide any additional information that might corroborate his alleged stressors. 3. Following the receipt of a response from the JSRRC, the RO should prepare a report detailing the nature of any stressor that it has determined is established by the record. If no stressor has been verified, the RO should so state in its report. This report is then to be added to the claims file. 4. Following completion of the above, the RO should obtain a VA psychiatric opinion to determine the presence and etiology of any acquired psychiatric disorders, including PTSD. Based on the examination and review of the record, the examiner is requested to provide the following opinion: Is it at least as likely as not (i.e., whether there is at least a 50 percent probability) that the Veteran had an acquired psychiatric disorder, including PTSD, related to active duty service? In answering this question, the RO should identify to the examiner the stressor deemed verified by VA, if any, and the examiner should be requested to identify the stressor that serves as the basis for any PTSD diagnosis. The examiner should also note the diagnostic criteria utilized to support the diagnosis under DSM-IV and should comment upon what specific symptoms are attributable to an acquired psychiatric disorder and/or PTSD, as opposed to symptoms referable to any nonservice-connected disabilities (whether mental and/or physical). If an acquired psychiatric disorder, other than PTSD is diagnosed, the VA examiner should provide an opinion as to the etiology of that psychiatric disorder. A rationale for all opinions expressed should be provided. The relevant documents in the claims file should be made available to and be reviewed by the examiner in conjunction with the examination. 5. Obtain a VA medical opinion in order to assist in determining the current nature and likely etiology of any melanoma of the left shoulder. Based on the examination and review of the record, the examiner is requested to provide the following opinion: Is it at least as likely as not (i.e., whether there is at least a 50 percent probability) that the Veteran had melanoma of the left shoulder, related to active duty service? In answering this question, please specifically discuss the Veteran's presumed exposure to Agent Orange during his service in Vietnam. A rationale for all opinions expressed should be provided. The relevant documents in the claims file should be made available to and be reviewed by the examiner in conjunction with the examination. 6. Readjudicate the claims of service connection for an acquired psychiatric disorder, including PTSD, and melanoma of the left shoulder. If the benefits sought remain denied, issue an appropriate supplemental statement of the case and provide the Veteran and representative the requisite period of time to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. The purpose of this remand is to provide assistance by further developing the record. The Board does not intimate any opinion as to the merits of the case, either favorable or unfavorable, at this time. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ T. D. JONES Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs